Basic Information
Provider Information | |||||||||
NPI: | 1487878559 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JUN | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | YOONKEUN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3355 GLENDALE AVE FL 3 | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436142426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5674201600 | ||||||||
FaxNumber: | 5674201633 | ||||||||
Practice Location | |||||||||
Address1: | 2100 W CENTRAL AVE FL 2 | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 43606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5674201600 | ||||||||
FaxNumber: | 5674201633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2007 | ||||||||
LastUpdateDate: | 07/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | MT187224 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 35.128476 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 0164737 | 05 | OH |   | MEDICAID |